Comparison of short-term outcomes between non-intubated and intubated video-assisted thoracoscopic surgery: a propensity score matching analysis

Introduction

The evolution of video-assisted thoracoscopic surgery (VATS) since Jacobaeus’ pioneering work in 1910 (1) has transformed thoracic surgical paradigms. Contemporary advancements in high-definition imaging and endoscopic instrumentation have established VATS as the gold standard for managing thoracic pathology, offering superior outcomes to open thoracotomy through minimized access trauma and enhanced recovery. Nevertheless, the conventional intubated VATS (IVATS) approach requiring one-lung ventilation (OLV) under general anesthesia presents inherent physiological challenges, including ventilator-related complications (2,3), postoperative pulmonary function impairment (4), and respiratory muscle dysfunction. These issues can even prolong mechanical ventilation (5), potentially hindering the patient’s postoperative recovery.

In recent years, the concept of Enhanced Recovery After Surgery (ERAS) has gained increasing attention. This approach emphasizes reducing surgical trauma, pain, and postoperative complications to promote better recovery outcomes for patients. Within this context, non-intubated VATS (NIVATS) has emerged as a novel surgical technique. By preserving the patient’s spontaneous respiration and eliminating the need for tracheal intubation and mechanical ventilation, NIVATS significantly reduces the incidence of related complications and effectively shortens hospital stays, making it a growing focus of research. Early studies have demonstrated that NIVATS is not only feasible and safe for minor thoracic surgeries (6) but also offers significant advantages over traditional intubated surgery in terms of shorter operative and hospital duration (7,8). Since 2011, our center has been at the forefront of adopting the NIVATS technique, successfully applying it to minor thoracic procedures such as pulmonary nodule wedge resection and thymectomy. With the continuous accumulation of surgical experience and the gradual refinement of techniques, the scope of NIVATS has expanded to include more complex procedures, such as radical lung cancer surgery and segmentectomy. These advancements have yielded satisfactory therapeutic outcomes in clinical practice. In recent years, the combination of robotic-assisted thoracoscopic surgery (RATS) with NIVATS has garnered attention and undergone preliminary exploration. This innovative surgical approach has demonstrated significant potential in the treatment of complex thoracic diseases (9).

Although NIVATS has demonstrated numerous potential advantages, there is still a lack of large-scale, multi-center, prospective randomized controlled trials to comprehensively evaluate its feasibility and safety compared to traditional intubated surgery during the perioperative period. No level I evidence from randomized controlled trials exists comparing NIVATS versus IVATS for major anatomical resections. In response to this gap, the present study systematically compared the therapeutic outcomes and safety profiles of NIVATS and IVATS across different patient groups with thoracic diseases. Our study aims to compare perioperative outcomes between NIVATS and IVATS, and to explore the potential applicability of NIVATS in selected clinical scenarios. We hypothesize that NIVATS, when applied to appropriately selected patients, may yield comparable or superior perioperative outcomes compared to IVATS. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-641/rc).

Methods

Study population and design

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by ethics board of The First Affiliated Hospital of Guangzhou Medical University (No. ES-2024-186-01) and informed consent was obtained from both the patient and their family members. and included a total of 4,537 patients who underwent VATS between January 2011 and December 2015. Based on the anesthesia approach, patients were divided into an NIVATS group and an IVATS group. For analytical purposes, surgical procedures were further categorized into two types according to complexity: minor procedures, including pleural, pulmonary, and mediastinal biopsies, peripheral wedge resections, thymectomies, and lung volume reduction surgery (LVRS); and major procedures, defined as anatomical lung resections (such as lobectomy or segmentectomy) and airway reconstructions. To minimize selection bias due to the retrospective and non-randomized nature of the study, propensity score matching (PSM) was performed separately for the minor and major procedure subgroups using a 1:1 matching ratio, resulting in 442 matched cases for minor procedures and 244 matched cases for major procedures. Clinical data were systematically extracted from the hospital’s electronic medical records system, including preoperative variables [age, sex, body mass index (BMI), smoking history, pulmonary function, and comorbidities], intraoperative variables (surgical approach, blood loss, and operative time), and postoperative outcomes (length of hospital stay and other recovery metrics).

Inclusion and exclusion criteria

Inclusion criteria

• Patients requiring thoracoscopic surgery due to thoracic diseases.
• American Society of Anesthesiologists (ASA) physical status classification ≤ grade 2.
• BMI <30 kg/m².
• Eastern Cooperative Oncology Group (ECOG) performance status ≤1.
• Normal cardiopulmonary function [ejection fraction (EF) >50%, forced expiratory volume in 1 second (FEV₁%) >50% of predicted value], with no major dysfunction of other vital organs, enabling surgical tolerance.
• No age restriction.

Exclusion criteria

• History of surgery on the ipsilateral thoracic cavity, potentially leading to severe pleural adhesions.
• Presence of severe bleeding disorders.
• Conversion to open thoracotomy during surgery.
• BMI ≥30 kg/m².
• Other conditions deemed unsuitable for surgery by the operating surgeon, including absolute surgical contraindications, pregnancy, or other unsuitable surgical conditions.

Preoperative preparation

Upon hospital admission, patients underwent a routine medical assessment, during which detailed clinical data were collected. This included information on gender, age, primary disease, comorbidities, family history, and smoking history. A series of related tests was then arranged, including complete blood count, blood typing, liver and kidney function tests, electrolyte panel, stool and urine analysis, and infectious disease screening. Chest X-rays and computed tomography (CT) scans were performed as standard procedures. For patients with tumors, additional examinations, such as full abdominal CT, bone scans, cranial magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT, were conducted to screen for potential metastatic lesions. All patients were also required to undergo electrocardiography, echocardiography, and pulmonary function tests to assess cardiopulmonary status. For patients with pre-existing cardiac conditions, further specialized examinations were arranged to ensure comprehensive evaluation.

For patients who smoked, strict smoking cessation was required before surgery. Patients were provided with educational guidance on proper coughing and sputum expectoration techniques, as well as pulmonary rehabilitation exercises. The primary nurse was responsible for psychological counseling, explaining postoperative care precautions, and assisting patients in preparing necessary postoperative supplies. Regarding preoperative preparation, patients were instructed to adhere to an 8-hour fasting and 6-hour fluid restriction protocol. On the day before surgery, patients were required to wear compression stockings to prevent deep vein thrombosis (DVT) in the lower limbs. Prior to surgery, the attending physician and anesthesiologist each provided detailed explanations of the surgical and anesthetic risks to the patient and their family.

Anesthesia

Anesthesia preparation and equipment

• Equipment and medications: monitoring equipment included an anesthesia machine, ventilator, electrocardiograph (ECG) monitor, and other necessary devices. Anesthetic agents such as propofol and etomidate were prepared. Instruments included tracheal tubes, laryngeal masks (LMA), and other essential tools. For surgeries requiring extracorporeal circulation, relevant equipment was also prepared in advance.
• Tracheal tube selection: in IVATS, tracheal tubes were selected based on the patient’s tracheal diameter; in NIVATS, double-lumen LMAs were chosen based on the patient’s body weight.

Anesthetic technique and induction

IVATS

For patients under 65 years of age, target-controlled infusion (TCI) of propofol was used for induction. For those over 65 years, etomidate was administered. After achieving airway muscle relaxation, a double-lumen endobronchial tube was inserted, and the patient was connected to a ventilator for OLV. Anesthesia was maintained with TCI propofol combined with remifentanil via micro-pump infusion or with a combination of intravenous and inhalational anesthetics.

NIVATS

Intravenous anesthesia was combined with somatic nerve blocks, with the most common protocol being intravenous anesthesia with intercostal nerve block and vagus nerve block. Propofol TCI was used for induction, followed by the placement of a double-lumen LMA while preserving spontaneous respiration. During the procedure, intercostal and vagus nerve blocks were performed. Anesthesia was maintained using propofol, remifentanil, and dexmedetomidine.

Intraoperative monitoring and problem management

During the surgery, continuous monitoring of vital signs, including blood pressure, oxygen saturation, and ECG, was performed, along with periodic arterial blood gas (ABG) analysis. Various measures were implemented to address potential intraoperative issues. For intraoperative coughing, anesthesia depth was increased, local anesthetic was applied, and a vagus nerve block was performed to suppress the response. In cases of hypoxemia, airway obstruction was ruled out, suctioning was performed, and oxygen flow was increased. Assisted ventilation was applied if necessary. Hypercapnia was managed through manual assisted ventilation or by using synchronized intermittent mandatory ventilation (SIMV) mode, with adjustments to reduce anesthetic depth as needed. If hypercapnia persisted despite these measures, intubation was considered. To resolve significant mediastinal swing, anesthetic dosage was adjusted, the dose of nerve block agents was increased, and assisted ventilation was applied. Conversion to tracheal intubation was required under conditions such as persistent hypoxemia, severe hypercapnia, large mediastinal swing, significant intrathoracic bleeding, excessive airway secretions, or frequent coughing.

Surgical procedure and postoperative care

Surgical procedure

The surgical procedures for NIVATS and IVATS are similar, with the primary difference being that NIVATS requires local infiltration anesthesia before VATS access. After VATS access, a trocar and thoracoscope are inserted for exploration, followed by intercostal and vagus nerve blocks. If oxygen saturation drops below 90% or apnea lasts for more than five minutes, the surgery is temporarily halted until oxygen levels are restored. The main instruments used include a thoracoscope and ultrasonic scalpel. Prophylactic antibiotics are administered 30 minutes to 1 hour before surgery, with additional doses given as needed. The patient is typically positioned in a lateral decubitus position on the healthy side. Surgical approaches vary and include three-port, two-port, and single-port techniques. For NIVATS thymectomy procedures, a left-sided lateral thoracoscopic approach using one or two ports was adopted, depending on tumor location. CO₂ insufflation was not used, as adequate exposure was achieved through spontaneous lung collapse, proper patient positioning, and nerve block techniques. To reduce mediastinal motion and suppress cough reflex during NIVATS, a vagal nerve block was routinely performed. Under thoracoscopic guidance, 3–5 mL of 0.5% ropivacaine was injected around the vagus nerve prior to lung manipulation. This technique provided satisfactory surgical conditions with minimal adverse effects.

Postoperative care

After surgery, patients were transferred to the post-anesthesia care unit (PACU), and further transfer to a hospital ward was determined based on the modified Aldrete score. Immediate postoperative bedside chest X-rays were performed to assess lung re-expansion, and routine monitoring of blood tests, including complete blood count, was conducted. For patients with a chest tube, drainage volume and color were closely observed to detect signs of active bleeding. Pain management included the use of non-steroidal anti-inflammatory drugs (NSAIDs) or opioids, with patient-controlled analgesia (PCA) pumps provided when necessary. Pain severity was assessed using the Visual Analog Scale (VAS): scores of 0–3 indicated no to mild pain, 4–6 indicated moderate pain that affected sleep but was tolerable, and 7–10 indicated severe pain.

Statistical methods

Data were analyzed using SPSS version 26.0. Continuous variables were expressed as mean ± standard deviation or median (interquartile range), and categorical variables were compared using the χ² test, with a significance level set at P≤0.05. To reduce selection bias, PSM was performed in a 1:1 ratio using a caliper width of 0.02. Matching variables included age, gender, BMI, smoking status, FEV₁, forced vital capacity (FVC), and comorbidity, which are known to influence perioperative outcomes and anesthesia selection. Comorbidity was defined as the presence of one or more chronic diseases (hypertension, diabetes mellitus, chronic obstructive pulmonary disease (COPD), coronary artery disease, or chronic kidney disease), and was treated as a binary variable (present or absent) during matching. To control for surgical complexity, PSM was conducted separately within minor and major procedure groups, thereby ensuring comparable surgical types across the matched NIVATS and IVATS cohorts. Patients who were initially assigned to the NIVATS group but required intraoperative conversion to intubated ventilation were still analyzed in the NIVATS group, following the intention-to-treat principle.

Results

Patient information

A total of 4,537 patients who underwent thoracoscopic surgery at the Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, between January 2011 and December 2015 were included in this study, with 960 patients receiving NIVATS and 3,577 patients undergoing IVATS. Based on the type of procedure performed, patients were categorized into two groups: the minor surgery group, consisting of 1,504 patients (714 NIVATS and 790 IVATS) who underwent pleural, pulmonary, or mediastinal biopsies, peripheral wedge resections, thymectomies, or LVRS; and the major surgery group, which included 3,033 patients (246 NIVATS and 2,787 IVATS) who underwent anatomical lung resections or airway reconstructions. To minimize confounding factors and baseline differences between the NIVATS and IVATS groups, PSM was conducted independently within each surgical subgroup using a 1:1 ratio, yielding 442 matched pairs in the minor procedure group and 244 matched pairs in the major procedure group.

Clinical characteristics before and after PSM

In the minor surgery cohort, a total of 1,504 patients were included prior to PSM, with 790 in the IVATS group and 714 in the NIVATS group. Statistical analysis revealed significant differences between the two groups across multiple clinical variables. The mean age was 37.5±18.7 years in the IVATS group and 35.6±17.0 years in the NIVATS group (P=0.04). The proportion of female patients was significantly higher in the NIVATS group (40.3%) compared to the IVATS group (13.5%) (P<0.01). The smoking rate was 18.5% in the IVATS group and 5.6% in the NIVATS group (P<0.01), indicating a higher prevalence of smoking among IVATS patients. The BMI was 20.0±2.7 kg/m² in the IVATS group and 20.7±3.1 kg/m² in the NIVATS group (P<0.01). Pulmonary function parameters showed significant differences: the FEV₁ was 2.4±0.8 L in the IVATS group and 2.9±0.9 L in the NIVATS group (P<0.01), while the FVC was 3.1±0.6 and 3.1±0.7 L, respectively (P=0.65), showing no difference. The rate of comorbidities was higher in the IVATS group (43.5%) than in the NIVATS group (14.4%) (P<0.01). After PSM, 422 matched pairs of patients were obtained. Most clinical characteristics showed no significant differences between the groups, except for age, gender, and FVC. Importantly, both matched cohorts retained a proportion of current smokers (31 in IVATS vs. 40 in NIVATS; P=0.16), indicating that smoking status was balanced but not excluded. The mean age was 35.3±17.7 years in the IVATS group and 38.6±17.5 years in the NIVATS group (P<0.01). The proportion of female patients remained higher in the NIVATS group (47.3% vs. 22.8%, P<0.01). The FVC was 3.2±0.7 L in the IVATS group and 3.0±0.7 L in the NIVATS group (P<0.01), although both values were within the normal range (Table 1).

In the major surgery cohort, a total of 3,033 patients were included before PSM, with 2,787 in the IVATS group and 246 in the NIVATS group. Significant differences were observed between the two groups across multiple clinical variables. The mean age was 58.8±12.0 years in the IVATS group and 50.3±14.4 years in the NIVATS group (P<0.01), indicating that IVATS patients were older. The proportion of female patients was higher in the NIVATS group (51.2%) compared to the IVATS group (42.3%) (P<0.01). The smoking rate was 21.2% in the IVATS group and 8.1% in the NIVATS group (P<0.01), suggesting a higher prevalence of smoking among IVATS patients. There was no significant difference in BMI between the groups, with values of 22.2±3.1 and 22.1±2.8 kg/m² for IVATS and NIVATS, respectively (P=0.89). Pulmonary function showed some differences: the FEV₁ was 2.4±0.7 L in the IVATS group and 2.6±0.7 L in the NIVATS group (P<0.01), while the FVC was 3.2±0.8 and 3.3±0.9 L, respectively (P=0.13), showing no significant difference. The rate of comorbidities was lower in the IVATS group (3.7%) compared to the NIVATS group (21.9%) (P<0.01). After PSM, 244 matched pairs of patients were obtained. No significant differences in clinical characteristics were observed between the two groups post-matching (Table 2).

Surgical outcomes after PSM

In the minor surgery cohort, no significant differences were observed between IVATS and NIVATS in terms of maximum end-tidal CO₂ (EtCO₂) and minimum saturation of peripheral oxygen (SpO₂). The SpO₂ values were 97.0%±10.3% for IVATS and 97.2%±8.4% for NIVATS (P=0.83), while the EtCO₂ values were 44.2±8.5 mmHg and 44.4±9.6 mmHg, respectively (P=0.84). However, there were significant differences in other surgical outcomes. The operative time for IVATS was 96.4±64.8 minutes, compared to 77.9±44.3 minutes for NIVATS (P<0.01), indicating a significantly shorter operative time for NIVATS. Intraoperative blood loss was 35.9±85.2 mL in the IVATS group and 20.9±49.7 mL in the NIVATS group (P<0.01), demonstrating that NIVATS was associated with significantly reduced blood loss. The length of hospital stay was also significantly shorter in the NIVATS group (5.2±3.8 days) compared to the IVATS group (6.5±5.2 days) (P<0.01), highlighting the potential of NIVATS to promote faster recovery (Table 3).

In the major surgery cohort, after PSM, IVATS and NIVATS showed no significant differences in maximum EtCO₂ or SpO₂. The SpO₂ values were 98.1%±2% for IVATS and 97.9%±2.6% for NIVATS (P=0.50), while the EtCO₂ values were 41.1±7.9 and 41.6±7.1 mmHg, respectively (P=0.50). However, significant differences were observed in surgical outcomes. The operative time for IVATS was 198.4±78.2 minutes, compared to 147.7±58.5 minutes for NIVATS (P<0.01), indicating that NIVATS was associated with a significantly shorter operative time. Intraoperative blood loss was 266.7±416.7 mL in the IVATS group and 72.3±126.2 mL in the NIVATS group (P<0.01), demonstrating that NIVATS significantly reduced blood loss. Additionally, the length of hospital stay was shorter in the NIVATS group (7.8±4.9 days) compared to the IVATS group (11.1±10.3 days) (P<0.01), highlighting that NIVATS can significantly reduce hospital stay duration (Table 4).

Discussion

This propensity-matched analysis of 4,537 VATS procedures establishes NIVATS as a physiologically protective strategy for both minor and major thoracic procedures that circumvents three principal iatrogenic insults inherent to conventional IVATS: (I) endotracheal intubation-induced airway trauma, such as postoperative sore throat (POST), hoarseness, and coughing (10), (II) mechanical ventilation-associated lung injury, and (III) neuromuscular blockade-related respiratory compromise. Our findings demonstrate that avoidance of these insults translates to quantifiable clinical benefits across surgical complexity tiers, with reductions in operative duration, less blood loss, and shorter hospitalizations versus IVATS-all achieved without compromising intraoperative stability (ΔSpO₂ <1.5%, ΔEtCO₂ <0.5 mmHg). These factors contribute to enhanced recovery for patients, supporting the adoption of NIVATS as a viable surgical approach (11).

In recent years, the concept of ERAS has gained increasing attention, with a growing trend toward minimally invasive surgical techniques. Traditional IVATS involves the use of a double-lumen tracheal tube and general anesthesia to achieve OLV, providing a stable and clear surgical field. However, tracheal intubation and mechanical ventilation can lead to various complications (12). For example, tracheal tubes may damage tracheal ciliated cells, resulting in POST and other discomforts, which can negatively impact postoperative recovery (13). A study by Jeon et al. demonstrated that, compared to IVATS, NIVATS can mitigate early postoperative changes in inflammatory cytokines following lung cancer resection (14), further highlighting its potential advantages in enhancing patient recovery and reducing postoperative complications.

OLV is one of the primary causes of lung injury associated with traditional IVATS, potentially leading to adverse events such as atelectasis, pulmonary infections, acute lung injury (ALI), and even acute respiratory distress syndrome (ARDS), thereby increasing the risk of postoperative mortality (15-17). According to the 2015 European Perioperative Clinical Outcome (EPCO) guidelines (18), postoperative pulmonary complications (PPCs)—including respiratory infections and atelectasis—are key contributors to postoperative mortality and delayed hospital discharge. The mechanisms of lung injury caused by OLV include barotrauma and volutrauma. Barotrauma can result in conditions such as interstitial emphysema and pneumomediastinum, while volutrauma, associated with high tidal volume ventilation, increases the risk of postoperative organ dysfunction (19). A meta-analysis by Guay et al. demonstrated that the use of low tidal volume ventilation during surgery can reduce postoperative complications in adults without pre-existing ALI (20).

Traditional IVATS requires the use of muscle relaxants, which are classified into depolarizing and non-depolarizing types. Both types may cause adverse effects, including muscle pain, allergic reactions, and arrhythmias (21). One of the major complications is residual neuromuscular blockade, which can delay the recovery of respiratory and swallowing muscles, increasing the risk of aspiration, delayed extubation, and postoperative airway complications. A study by Kirmeier et al. demonstrated that the use of muscle relaxants during IVATS is associated with a higher incidence of pulmonary complications (22). In contrast, NIVATS does not require the use of muscle relaxants during surgery, which may contribute to its ability to accelerate patient recovery, reduce hospital stay duration, and lower the risk of postoperative complications.

In terms of perioperative analgesia, traditional IVATS often requires moderate to high doses of opioids, which can lead to adverse effects such as gastrointestinal reactions and respiratory depression (23). A study by Kurteva et al. found that patients using opioids experienced prolonged hospital stays, increased medical costs, higher risks of readmission, and elevated in-hospital mortality rates (24). In contrast, NIVATS utilizes intravenous anesthesia combined with somatic nerve blocks, which significantly reduces the intraoperative opioid dosage and minimizes associated side effects (25). Research by Liang H further confirmed that patients undergoing NIVATS required less postoperative opioid use and experienced faster recovery (26).

The foundation of NIVATS is artificial pneumothorax, which can lead to intraoperative complications such as hypoxemia and hypercapnia. However, hypoxemia is uncommon, possibly due to compensatory factors such as preserved diaphragmatic function, which enhances oxygenation (27). In this study, intraoperative oxygen saturation levels were maintained within normal ranges in both NIVATS and IVATS groups, with no significant differences observed, indicating that NIVATS is both safe and feasible. Hypercapnia is a common complication in NIVATS, but mild to moderate hypercapnia is generally acceptable and does not compromise surgical safety. It can typically be resolved through controlled ventilation (28). Gonzalez-Rivas et al. reported that the use of an LMA during NIVATS for lobectomy effectively prevented intraoperative carbon dioxide accumulation (29). In this study, no cases of hypercapnia were observed in the NIVATS group, possibly due to the routine use of LMAs. However, further research is needed to fully address the issue of carbon dioxide retention.

Previous studies have confirmed the safety and advantages of NIVATS in both minor and major thoracic surgeries, including shorter hospital stays, reduced operative time, and decreased blood loss (30). Yu et al. demonstrated that NIVATS facilitates early recovery, reduces medical costs, and shortens the duration of postoperative chest tube drainage (31). Similarly, a meta-analysis by Xue et al. showed that NIVATS had no significant difference in postoperative complication rates compared to IVATS but resulted in faster recovery (32). Research by Zhang et al. reached similar conclusions, highlighting that NIVATS is associated with lower postoperative complication rates, quicker discharge, and reduced perioperative mortality (33). Furthermore, NIVATS has shown advantages in complex procedures, such as tracheal surgeries, by lowering surgical difficulty and shortening operative time (6).

In summary, NIVATS offers several advantages: it eliminates tracheal tube-related injuries, avoids mechanical ventilation-associated damage, does not require the use of muscle relaxants, reduces opioid usage, shortens operative time, minimizes trauma, and leads to shorter hospital stays. However, this study is limited to a retrospective analysis of cases from a single center, which may restrict the generalizability of the conclusions. Large-scale, prospective, multi-center clinical trials are needed to further validate the safety and efficacy of NIVATS.

Although our findings support the physiological rationale for NIVATS, we did not assess specific complications such as POST, hoarseness, or pulmonary adverse events due to inconsistent documentation in the historical dataset. In addition, intraoperative conversions from NIVATS to IVATS (unplanned tracheal intubation) were not systematically recorded and were excluded according to our predefined criteria, preventing further analysis of their frequency or clinical impact. These limitations underscore the need for future prospective studies with standardized complication tracking and conversion reporting to provide direct clinical evidence for the safety and feasibility of NIVATS.

Despite the demonstrated benefits of NIVATS, surgeons must navigate several technical challenges associated with the non-intubated approach. Maintaining adequate visualization and operative field exposure can be difficult due to lung motion and spontaneous breathing. Additionally, the absence of muscle relaxation and endotracheal control requires careful coordination with anesthesiologists and vigilant intraoperative monitoring to prevent hypoxemia or hypercapnia. Procedures near the hilum or great vessels require special caution, as unexpected bleeding may necessitate emergency conversion. Surgeons performing NIVATS must be proficient in thoracoscopic techniques and prepared with clear conversion protocols. With appropriate patient selection and growing experience, these pitfalls can be managed effectively, allowing safe and reproducible outcomes.

Conclusions

In terms of short-term outcomes, NIVATS is safe for both minor and major thoracic surgeries. Compared to IVATS, it offers advantages such as shorter operative time, reduced blood loss, and shorter hospital stays. However, since this study is based on a retrospective analysis of cases from a single center, the findings have certain limitations. Further validation through large-scale, prospective, multi-center clinical trials is necessary to confirm the safety and efficacy of NIVATS.

Acknowledgments

Part of this study was presented at the 27th European Society of Thoracic Surgeons (ESTS) Meeting.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-641/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-641/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-641/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-641/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by ethics board of The First Affiliated Hospital of Guangzhou Medical University (No. ES-2024-186-01) and informed consent was obtained from both the patient and their family members.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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